Progressing from patienthood to personhood across the multidimensional outcomes in schizophrenia and related disorders

People with mental illness stigmatize mental illness less: A comparison study between a hospital-based sample of people with mental illness and a non-clinical general population sample in urban India

Evidence shows that stigma negatively influences the quality of life of persons with severe mental illness. Nonetheless, stigma towards mental illness is lower among persons with a lived experience of mental illness compared to the rest of the population. Understanding the association between stigma of mental illness and the mental status of individuals living in urban India and whether this association is moderated by demographic factors opens a new avenue for prevention of social exclusion. Persons diagnosed with schizophrenia, bipolar disorder, or severe unipolar depression (cases, n  =  647) were recruited from among hospital patients in New Delhi between November 2011 and June 2012 and matched with non-psychiatric urban dwellers by age, sex, and location of residence (controls, n  =  649). Propensity score matching with multivariable linear regression was used to test whether stigma towards mental illness, measured by a 13-item Stigma Questionnaire, differed between cases and controls. Cases reported significantly lower stigma scores than controls (b  =  -0.50, p < 0.0001). The strength of the association between mental illness and stigma was not affected after controlling for age, caste, sex, education, and employment status, while wealth marginally reduced the strength of the association. These findings suggest individuals with a lived experience of mental illness, in New Delhi, India, may be more tolerant towards mental illness and support the need to involve persons with lived experience in the development and implementation of health promotional campaigns and programs aimed at reducing stigma towards mental illness.

No evidence that implicit identification with mental illness predicts recovery

OBJECTIVES

Recovery from mental illness is multiply-determined, but one factor that has been proposed to influence recovery is the degree to which the person identifies as someone with a mental illness. This study examines the relationship between implicit identification with being mentally unwell and recovery among clients of a community mental health service. A multi-faceted view of recovery was adopted.

METHODS

A longitudinal design was used to assess implicit identification with mental illness and its relationship to recovery, including symptom severity, well-being, life satisfaction, and optimism, which were supplemented with ratings by both support workers and the research assistants who conducted the study. Participants were 216 community mental health care clients, with 150 retested at Time 2, and 100 retested at Time 3.

RESULTS

Implicit identification with mental illness was correlated with recovery at Time 1 and Time 3, though this relationship did not emerge at Time 2. Cross-lag regression analyses failed to reveal evidence that implicit identification with mental illness predicts subsequent recovery.

CONCLUSIONS

The current research suggests that implicit identification with mental illness can be considered a marker of ongoing recovery, but is not predictive of subsequent recovery. Hence, these data suggest that implicit identification with mental illness is unlikely to play an independent role in the recovery process.

PRACTITIONER POINTS

Research regarding the mental health consequences of implicit identification focuses on symptomatology. Recovery is more than a reduction in symptoms, however, and thus, a broader conceptualization of recovery was examined. Implicit identification with being mentally unwell was associated with poorer recovery broadly operationalized, but did not predict subsequent recovery.

Self-concept and Engagement in LiFe (SELF): A waitlist-controlled pilot study of a novel psychological intervention to target illness engulfment in enduring schizophrenia and related psychoses

BACKGROUND

Illness engulfment, a process whereby one's self-concept becomes defined entirely by illness, is implicated in the association between insight and depressive symptomatology in schizophrenia. We examined the feasibility and acceptability of a brief intervention called Self-concept and Engagement in LiFe (SELF) that aims to reduce engulfment and enhance personal recovery.

METHODS

Forty individuals diagnosed with schizophrenia spectrum disorders were assigned to SELF intervention or waitlist-control (treatment-as-usual). Outcome measures included the Modified Engulfment Scale and measures of depressive symptomatology, self-esteem, recovery style, quality of life, and self-stigma.

RESULTS

Retention at post-therapy was 90% (18/20 completed SELF; 18/20 remained on waitlist). Eleven waitlist participants then completed SELF (73% overall retention). Participants reported high satisfaction with the intervention, and participation was associated with reduced engulfment (ES = 0.48), more adaptive recovery style (ES = 0.37), improved self-esteem (ES = 0.35), and reduced self-stigma (ES = 0.25). The treatment group had lower engulfment (adjusted mean = 91.9) compared to waitlist (adjusted mean = 100.0) post-therapy, F (1,32) = 5.78, p = .02, partial η² = 0.15.

CONCLUSIONS

The SELF intervention is highly acceptable to participants and can reduce engulfment and improve secondary outcomes. Future research should examine the efficacy of SELF in a larger randomized controlled trial.

Evaluation of an occupation-based, mental-health program: Meeting being, belonging and becoming needs

INTRODUCTION

Being, belonging and becoming are important theoretical constructs for occupational scientists and therapists, and for members of Northern Initiative for Social Action (NISA), located in northern Ontario, Canada. Collaborative research with service users guided the development of NISA and its evaluation tool: the 3B~S Scale. The aim of this paper is to share the results of the 2018 program evaluation.

METHODS

113 participants completed a questionnaire consisting of the 3B~S Scale, demographic and program satisfaction questions, and open-ended questions. Quantitative analysis used descriptive statistics followed by ordinal logistic regression to determine the intersectional effects of gender, race and age on becoming and system impact outcomes. Open-ended responses were analysed thematically and triangulated with quantitative findings.

RESULTS

Participants agreed-to-strongly agreed that the program met their 3B needs (x = 4.20, SD = 0.24). Participants indicated strong satisfaction with the program (x = 4.38, SD = 0.66), and agreement that participating in the program reduced their reliance on other system-based services (x = 3.96, SD = 0.24). The regression revealed no significant differences in gender, race or age in predicting six of 10 outcomes examined; race was not significant for any outcome. Younger females were more likely to agree that the work they do is part of a larger community charitable purpose, the program is helping them to achieve their goals, and is increasing their involvement in community. Younger participants were more likely to agree that participation facilitated a return to school or employment than older participants.

CONCLUSIONS

Occupation-based, mental health programs that address participants' being, belonging and becoming needs can contribute to improvements in perceived mental health and well-being, as well as to improved community and system usage outcomes. The NISA model provides a framework for clinically operationalising the 3B's and may provide a unique contribution to ongoing theoretical discussions of these constructs within occupational therapy and science.

From Fragmentation to Coherence: Psychodynamic Psychotherapy for Psychosis through the Lens of Metacognition

Psychoanalysis has produced important theories that help explain the radical alterations in self-experience central for persons experiencing psychosis. These concepts have led to important clinical developments, case studies, and some research on the efficacy of psychodynamic psychotherapy for psychosis (Gottdiener, 2006). However, psychodynamic psychotherapy has struggled to produce operationalized constructs to measure how it enhances self-development and the therapeutic mechanisms of action that facilitate these changes. Outside of psychoanalysis, some researchers have focused on the construct of metacognition (i.e. thinking about thinking) and its relevance to understanding psychosis. Proponents of this paradigm have created an integrative, exploratory therapy (MERIT, Lysaker & Klion, 2017) that blends various therapeutic traditions that overlap with psychodynamic psychotherapy and mentalization (Ridenour, Knauss, & Hamm, 2019). In this paper, we will present a short-term intensive case study of psychodynamic psychotherapy with a young man experiencing psychosis in residential treatment and then analyze the therapy through the lens of metacognition to provide constructs that illustrate the ways that it promotes recovery and self-integration.

Enhancing return to work or school after a first episode of schizophrenia: the UCLA RCT of Individual Placement and Support and Workplace Fundamentals Module training

BACKGROUND

This study evaluated in a rigorous 18-month randomized controlled trial the efficacy of an enhanced vocational intervention for helping individuals with a recent first schizophrenia episode to return to and remain in competitive work or regular schooling.

METHODS

Individual Placement and Support (IPS) was adapted to meet the goals of individuals whose goals might involve either employment or schooling. IPS was combined with a Workplace Fundamentals Module (WFM) for an enhanced, outpatient, vocational intervention. Random assignment to the enhanced integrated rehabilitation program (N = 46) was contrasted with equally intensive clinical treatment at UCLA, including social skills training groups, and conventional vocational rehabilitation by state agencies (N = 23). All patients were provided case management and psychiatric services by the same clinical team and received oral atypical antipsychotic medication.

RESULTS

The IPS-WFM combination led to 83% of patients participating in competitive employment or school in the first 6 months of intensive treatment, compared with 41% in the comparison group (p < 0.005). During the subsequent year, IPS-WFM continued to yield higher rates of schooling/employment (92% v. 60%, p < 0.03). Cumulative number of weeks of schooling and/or employment was also substantially greater with the IPS-WFM intervention (45 v. 26 weeks, p < 0.004).

CONCLUSIONS

The results clearly support the efficacy of an enhanced intervention focused on recovery of participation in normative work and school settings in the initial phase of schizophrenia, suggesting potential for prevention of disability.

'Recovery' in the Real World: Service User Experiences of Mental Health Service Use and Recommendations for Change 20 Years on from a First Episode Psychosis

Little is known about how recovery oriented policy and legislative changes influence service users’ perceptions of mental health care over time. Although the recovery approach is endorsed in many countries, qualitative research examining its impact on service use experiences has been lacking. This study aimed to explore this impact as well as experiences of service utilisation and suggestions for change with people diagnosed with a First Episode Psychosis between 1995 and 1999. Participants had used services during the 10 year period prior to, and 10 years post, policy and legislative shifts to the recovery approach. Semi-structured interviews were conducted with 10 participants who met criteria for ‘full functional recovery’ and 10 who did not. Data were analysed using Thematic Networks Analysis to develop Basic, Organising, and Global Themes. Over time, recovered participants perceived an improvement in service quality through the ‘humanising’ of treatment and non-recovered participants experienced their responsibility in recovery being recognised, but felt abandoned to the recovery approach. Findings suggest the importance of viewing service users as demonstrating personhood and having societal value; examining the personal meaning of psychotic experiences; and matching expectations with what services can feasibly provide. The implementation and the principal tenets of the recovery approach warrant further investigation.

A Disorder by Any Other Name: Metacognition, Schizophrenia, and Diagnostic Practice

Humanistic psychology has made us aware that any understanding of schizophrenia must see persons diagnosed with this condition as whole persons who are making sense of what wellness and recovery mean to them. This has raised questions about what the diagnosis of schizophrenia means and whether the diagnostic label of schizophrenia is helpful when we try to conceptualize the actions and aims of treatment. To examine this issue we propose it is essential to consider what is systematically occuring psychologicaly in recovery when persons experience, interpret and agentically respond to emerging challenges. We then review how the integrated model of metacognition provides a systematic, person-centered, evidence-based approach to understanding psychological processes which impact recovery, and discuss how this guides a form of psychotherapy, metacognitive reflection and insight therapy, which promotes metacognitive abilities and support recovery. We suggest this work indicates that metacognitive capacity is something that can be diagnosed without stigmatizing persons. It can be used to meaningfully inform clinical practice across various theoretical models and offers concrete implications for rehabilitation.

Qualitative process evaluation of a psycho-educational intervention targeted at people diagnosed with schizophrenia and their primary caregivers in Jordan

BACKGROUND

Schizophrenia is a serious form of mental illness that often requires long term care. Empirical findings indicate that combining a psycho-educational intervention (PEI) with neuroleptic medication to treat schizophrenia is effective. However, there is little information on the therapeutic mechanism of PEIs.

METHODS

A qualitative process evaluation was conducted with a purposive sample of people diagnosed with schizophrenia (PDwS, n = 8) and their Primary Caregivers (PCs, n = 9) who had received PEI as a part of an exploratory randomized controlled trial. Semi-structured interviews were conducted to explore potential processes underpinning any observed effect. Thematic analysis was used to analyze and identify prominent patterns in the data. Interviews were conducted between April 2013 and August 2013.

RESULTS

Three themes emerged from the qualitative interviews, 'Awareness of schizophrenia', 'Positive impact on health and wellbeing', 'empowerment and enhanced confidence', which described the variety of experiences with the intervention, although most reported that the intervention was acceptable and valued.

CONCLUSION

This study identified that individual understanding varied between PDwS and PCs and led to differences in the ways that they used knowledge gained from the PEI in everyday situations. These data support the importance of improving understanding of schizophrenia by PDwS and their PCs to enable them to benefit more fully from medication.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN78084871 . Retrospectively registered 28 December 2015.

Subjective Experiences of the Benefits and Key Elements of a Cognitive Behavioral Intervention Focused on Community Work Outcomes in Persons With Mental Illness

New research suggests that group-based cognitive behavioral therapy (CBT) may help improve employment outcomes in persons with mental illness, yet the effects and potential key elements facilitating change in such interventions are unclear. Using a mixed methods approach, this study examined the perspectives of persons with mental illness after participating in a pilot study of the "CBT for Work Success" intervention. Findings demonstrate that participants valued the intervention and perceived that it assisted them in achieving work goals. Therapeutic effects included improved self-efficacy, work motivation, enhanced sense of self as workers, and increased beliefs that work success is attainable. CBT for Work Success elements perceived to be important in facilitating work goals included cognitive restructuring, behavioral coping strategies, problem solving work barriers, meaningful reflection on oneself as a worker, and important factors associated with the group process. The authors discuss the implications of these findings and future research directions.

Stages of recovery in early psychosis: Associations with symptoms, function, and narrative development

OBJECTIVES

This study sought to explore the links between recovery stages, symptoms, function, and narrative development among individuals with a recent onset of psychosis.

DESIGN

A qualitative longitudinal study was conducted including quantitative data at baseline.

METHODS

Forty-seven participants were administered the Indiana Psychiatric Illness Interview three times over 9 months and content analysis was performed. Participants also completed the Social Functioning Scale, the Brief Psychiatric Rating Scale--Expanded, the California Verbal Learning Test, and the Trailing Making Test at baseline. Descriptive discriminant analysis was performed.

RESULTS

Results suggested that participants were mostly in the first two stages of recovery (moratorium, awareness) and that being in the awareness, rather than moratorium, stage was associated, to a different extent, with richer narrative development, better levels of psychosocial function, less negative and positive symptoms, and more years of education. Furthermore, recovery appeared to be a stable process over the assessment period.

CONCLUSIONS

Recovery is a complex concept including objective and subjective aspects. In the recovery path of persons recently diagnosed with psychosis, social engagement, narrative development, and occupational functioning seem to be particularly important aspects. This study is a first step, and future research is needed with larger and more diverse participant pools, and assessments conducted over longer periods of time.

PRACTITIONER POINTS

As greater level of social engagement was the most robust predictor of membership in the awareness versus moratorium stage, treatment of early psychosis should include interventions targeting social relations and social skills. As greater narrative development was the second most robust predictor, enhancing it via psychotherapy could be a pertinent clinical goal.

Strong subjective recovery as a protective factor against the effects of positive symptoms on quality of life outcomes in schizophrenia

BACKGROUND

Interest in recovery from schizophrenia has been growing steadily, with much of the focus on remission from psychotic symptoms and a return to functioning. Less is known about the experience of subjective recovery and its relationships with other important outcomes, such as quality of life and the formation and sustenance of social connections. This study sought to address this gap in knowledge by examining the links between self perceived recovery, symptoms, and the social components of quality of life.

METHODS

Sixty eight veterans with schizophrenia-spectrum disorders who were participating in a study of cognitive remediation and work were concurrently administered the Recovery Assessment Scale, Positive and Negative Syndrome Scale, and the Heinrichs-Carpenter Quality of Life Scale (QLS).

RESULTS

Linear regression analyses demonstrated that subjective recovery moderated the relationship between positive symptoms and both QLS intrapsychic foundations scores and QLS instrumental role functioning after controlling for negative symptoms. Further examination of this interaction revealed that for individuals with substantial positive symptoms, higher levels of subjective recovery were associated with better instrumental role functioning and intrapsychic foundational abilities.

CONCLUSION

Greater self perceived recovery is linked with stronger quality of life, both in regards to the cognitive and affective bases for socialization and active community involvement, even in the presence of substantial psychotic symptoms. Clinical implications of these findings are discussed.

Reducing self-stigma by coming out proud

Self-stigma has a pernicious effect on the lives of people with mental illness. Although a medical perspective might discourage patients from identifying with their illness, public disclosure may promote empowerment and reduce self-stigma. We reviewed the extensive research that supports this assertion and assessed a program that might diminish stigma's effect by helping some people to disclose to colleagues, neighbors, and others their experiences with mental illness, treatment, and recovery. The program encompasses weighing the costs and benefits of disclosure in deciding whether to come out, considering different strategies for coming out, and obtaining peer support through the disclosure process. This type of program may also pose challenges for public health research.

Outcomes that matter: a qualitative study with persons with schizophrenia and their primary caregivers in India

BACKGROUND

Involving persons with schizophrenia and their families in designing, implementing and evaluating mental health services is increasingly emphasised. However, there is little information on desired outcomes from the perspectives of these stakeholders from low and middle income countries (LMIC).

AIMS

To explore and define outcomes desired by persons with schizophrenia and their primary caregivers from their perspectives.

METHOD

In-depth interviews were held with 32 persons with schizophrenia and 38 primary caregivers presenting for care at one rural and one semi-urban site in India. Participants were asked what changes they desired in the lives of persons affected by the illness and benefits they expected from treatment. Data was analysed using thematic and content analysis.

RESULTS

Eleven outcomes were desired by both groups: symptom control; employment/education; social functioning; activity; fulfilment of duties and responsibilities; independent functioning; cognitive ability; management without medication; reduced side-effects; self-care; and self-determination. Social functioning, employment/education and activity were the most important outcomes for both groups; symptom control and cognitive ability were more important to persons with schizophrenia while independent functioning and fulfilment of duties were more important to caregivers.

CONCLUSIONS

Interventions for schizophrenia in India should target both clinical and functional outcomes, addressing the priorities of both affected persons and their caregivers. Their effectiveness needs to be evaluated independently from both perspectives.

Self-esteem as a mediator of the relationship between role functioning and symptoms for individuals with severe mental illness: a prospective analysis of Modified Labeling theory

BACKGROUND

Despite a growing body of evidence supporting the efficacy of psychosocial rehabilitation for individuals with severe mental illness (SMI), a large proportion of these individuals remain unable to maintain basic social roles such as employee, parent, or spouse. This study investigated whether changes in role functioning over time impact symptom severity indirectly through the mechanism of changes in self-esteem as posited by Modified Labeling theory.

METHODS

The study sample was composed of 148 individuals diagnosed with schizophrenia, schizoaffective disorder, bipolar disorder with psychotic features, and major depression with psychotic features who elected to participate in community-based psychosocial rehabilitation services. Measures of role functioning, self-esteem, and psychiatric symptoms were gathered at baseline and six months through a combination of structured clinical interviews and self-report surveys.

RESULTS

SEM results at baseline provided support for a model in which self-esteem fully mediated the relationship between role functioning and psychiatric symptoms. The final model explained 20% of the variance in psychiatric symptoms. Analyses at six months post-baseline (time 2) indicate that changes in self-esteem fully mediated the relationship between changes in role functioning and changes in psychiatric symptoms. The final change model explained 23% of the variance in changes in psychiatric symptoms.

CONCLUSION

Results provide empirical support for the principles underlying Modified Labeling theory. Implications include the need for interventions that focus on social participation as a means of improving self-esteem, thereby decreasing symptom exacerbation and future relapse for people with SMI.

Self-stigma and stages of change as predictors of treatment adherence of individuals with schizophrenia

The current study aimed at exploring the relationship between self-stigma, readiness for change and psychosocial treatment adherence among individuals with schizophrenia. Between March 2007 and January 2008, 105 adults with schizophrenia were recruited for this cross-sectional study. Face-to-face interviews were conducted to assess participants' level of self-stigma, readiness for change, insight, and general self-efficacy. The corresponding case therapists reported participants' level of treatment adherence, psychopathology, and global functioning. Findings of stepwise multiple regression suggested that individuals with higher global functioning, better readiness for action, and lower level of self-stigma demonstrated better treatment participation. Individuals with lesser severity of psychiatric symptoms and female participants had better treatment attendance. The results of discriminant function analysis showed the combined score of self-stigma, stages of change, and global functioning measures correctly classified 76.2% participants into adherent/nonadherent group membership. Suggestions for further studies and development of self-stigma reduction program to facilitate recovery and treatment adherence were made.

First episode psychosis and employment: a review

Despite considerable growth in treatments, interventions, services and research of young people with a first episode of psychosis, little attention has been given to the priorities of these young people, in particular, gaining employment. A literature review was undertaken with the aim of investigating: 1) whether young people with a first episode of psychosis want to work, 2) what challenges they experience regarding work, 3) what is understood about employment outcomes, 4) what the most effective interventions to enable them to gain employment may be, and 5) what the associated costs may be. The review found that these young people appear to want to work yet face a range of psychological and social challenges to achieving this. Typically by the time they first come into contact with mental health services a proportion are already falling out of education and employment, and this decline continues with contact with services. However, there are specific interventions that can support them to gain employment. The Individual Placement and Support approach, adapted to include support to fulfil educational goals, has demonstrated that a mean of 69% of young people with a first episode of psychosis can gain education and employment compared to 35% of controls.

Internalized stigma as a barrier to improvement in vocational functioning among people with schizophrenia-spectrum disorders

We examined the relationship between internalized stigma and changes in vocational function. Persons with schizophrenia or schizoaffective disorder (n=78) were assessed at baseline and 5 months after vocational rehabilitation. Internalized stigma and cognitive-behavioral treatment predicted change in vocational functioning, supporting the view that internalized stigma compromises vocational outcomes.

The Impact of Illness Identity on Recovery from Severe Mental Illness

The impact of the experience and diagnosis of mental illness on one's identity has long been recognized; however, little is known about the impact of illness identity, which we define as the set of roles and attitudes that a person has developed in relation to his or her understanding of having a mental illness. The present article proposes a theoretically driven model of the impact of illness identity on the course and recovery from severe mental illness and reviews relevant research. We propose that accepting a definition of oneself as mentally ill and assuming that mental illness means incompetence and inadequacy impact hope and self-esteem, which further impact suicide risk, coping, social interaction, vocational functioning, and symptom severity. Evidence supports most of the predictions made by the model. Implications for psychiatric rehabilitation services are discussed.

Psychotherapy and recovery from schizophrenia: A review of potential applications and need for future study

Recovery from schizophrenia has been conceptualized to involve not only symptom remission of symptoms and achievement of psychosocial milestones but also subjective changes in how persons appraise their lives and the extent to which they experience themselves as meaningful agents in the world. In this paper we review the potential of individual psychotherapy to address these more subjective aspects of recovery. Literature on the effectiveness of psychotherapy for persons with schizophrenia is discussed and two different paths by which psychotherapy might modify self-experience are described. First we detail how psychotherapy could be conceptualized and tailored to help persons with schizophrenia to construct richer and fuller narrative accounts of their lives including their strengths, challenges, losses and hopes. Second we explore how psychotherapy could target the capacity for metacognition or thinking about thinking, assisting persons with psychosis to become able to think about themselves and others in a generally more complex and flexible manner. The needs for future research are discussed along with a commentary on how current evidence- and skill-based treatments may contain key elements which could be considered psychotherapeutic.

Psychotherapy of Schizophrenia: A Brief History and the Potential to Promote Recovery

With growing awareness of the likelihood of recovery from schizophrenia, interest has arisen about the potential role of psychotherapy within emerging treatment regimens. Could psychotherapy uniquely promote recovery by addressing symptoms, the achievement of psychosocial milestones, and/or helping to enhance the extent to which persons diagnosed with schizophrenia experience themselves as meaningful agents in the world? As an introduction to a set of case studies of how psychotherapy can promote recovery this article briefly reviews the history of the psychotherapy of schizophrenia. In particular the appearance and course of psychoanalytically oriented treatments, as well as cognitively and interpersonally based treatments are detailed. Evidence supporting these approaches and remaining questions for research are discussed.

A stress-coping model of mental illness stigma: I. Predictors of cognitive stress appraisal

Stigma can be a major stressor for individuals with schizophrenia and other mental illnesses. It is unclear, however, why some stigmatized individuals appraise stigma as more stressful, while others feel they can cope with the potential harm posed by public prejudice. We tested the hypothesis that the level of perceived public stigma and personal factors such as rejection sensitivity, perceived legitimacy of discrimination and ingroup perceptions (group value; group identification; entitativity, or the perception of the ingroup of people with mental illness as a coherent unit) predict the cognitive appraisal of stigma as a stressor. Stigma stress appraisal refers to perceived stigma-related harm exceeding perceived coping resources. Stress appraisal, stress predictors and social cue recognition were assessed in 85 people with schizophrenia, schizoaffective or affective disorders. Stress appraisal did not differ between diagnostic subgroups, but was positively correlated with rejection sensitivity. Higher levels of perceived societal stigma and holding the group of people with mental illness in low regard (low group value) independently predicted high stigma stress appraisal. These predictors remained significant after controlling for social cognitive deficits, depressive symptoms and diagnosis. Our findings support the model that public and personal factors predict stigma stress appraisal among people with mental illness, independent of diagnosis and clinical symptoms. Interventions that aim to reduce the impact of stigma on people with mental illness could focus on variables such as rejection sensitivity, a personal vulnerability factor, low group value and the cognitive appraisal of stigma as a stressor.

Pathways between internalized stigma and outcomes related to recovery in schizophrenia spectrum disorders

OBJECTIVE

The mechanisms by which internalized stigma affects outcomes related to recovery among people with severe mental illness have yet to be explicitly studied. This study empirically evaluated a model for how internalized stigma affects important outcomes related to recovery.

METHODS

A total of 102 persons with schizophrenia spectrum disorders completed measures of internalized stigma, awareness of mental illness, psychiatric symptoms, self-esteem, hopefulness, and coping. Path analyses tested a predicted model and an alternative model for the relationships between the variables.

RESULTS

Results from model 1 supported the view that internalized stigma increases avoidant coping, active social avoidance, and depressive symptoms and that these relationships are mediated by the impact of internalized stigma on hope and self-esteem. Results from model 2 replicated significant relationships from model 1 but also supported the hypothesis that positive symptoms may influence hope and self-esteem.

CONCLUSIONS

Findings from two models supported the hypothesis that internalized stigma affects hope and self-esteem, leading to negative outcomes related to recovery. It is recommended that interventions be developed and tested to address the important effects of internalized stigma on recovery.

A functional MRI study of Theory of Mind in euthymic bipolar disorder patients

OBJECTIVES

To determine the neural responses invoked in Theory of Mind (ToM) in euthymic bipolar patients as compared with healthy subjects.

METHODS

This study examined 20 euthymic bipolar patients (11 males and 9 females) and 20 suitably matched healthy subjects using functional magnetic resonance imaging (fMRI) while subjects were engaged in a ToM task. Within-scanner eye movements were monitored to ensure task engagement. The activation paradigm involved observing ToM and random-motion animated sequences in a block design. Both within group (ToM versus random motion) and random effects between group analyses were performed on fMRI data using the BrainVoyager software package. Demographic and clinical data, along with subject ratings of fMRI stimuli, were collated and analysed.

RESULTS

Patients were compromised in their ability to appropriately rate the ToM stimuli and assess them for intention as compared to healthy subjects. This was reflected in the fact that patients had few within-group significant activations in response to ToM animated sequences, namely, the left anterior cingulate, and precuneus and cuneus bilaterally. In contrast, robust activations in response to ToM animated sequences in healthy subjects were widespread and involved regions recognized for mental state reasoning, in particular the insula, inferior frontal, supramarginal and angular gyri, and temporal cortex. The between-group random effects analysis exclusively favoured the healthy subjects, with many activations occurring in regions overlapping with those found in the within-group analyses.

CONCLUSIONS

The findings of this novel neuroimaging study suggest that in a social context, euthymic bipolar patients, though seemingly well and capable of engaging aspects of ToM, are perhaps constrained in their ability to mentalize fully, and furthermore cannot reliably adopt an alternate cognitive perspective when appropriate. Impairment of this capacity, though subtle, may in effect compromise their ability to understand the emotions and intentions of others, and also may limit appreciation of their own illness and symptoms. Such a deficit in bipolar disorder perhaps impacts upon interpersonal relationships and adversely affects social cognition and clinical functioning. The potential implications of this putative mentalizing compromise in euthymic patients with bipolar disorder are substantial, both for the individual and for understanding the neural substrate of the illness, and therefore warrant further investigation.

A qualitative inquiry into the Taiwanese mentally ill persons' difficulties living in the community

Community care has been a paradigm shift for psychiatric treatment worldwide; however, it has not been successfully implemented in many developing countries, including Taiwan. This qualitative study aimed to explore the Taiwanese mentally ill persons' difficulties living in the community. Social disadvantages and illness adaptation were recognized as two domains of difficulties encountered by Taiwanese mentally ill patients living in the community, while six themes were identified: getting a "shameful" illness, unmet needs for community care, being overcome by a distorted world, denying the illness, living with the illness, and adapting to changed level of functioning. Related cultural issues were also discussed.

Know yourself and you shall know the other... to a certain extent: multiple paths of influence of self-reflection on mindreading

Social and neurocognitive research suggests that thinking about one's own thinking and thinking about the thinking of others-termed 'mindreading', 'metacognition', 'social cognition' or 'mentalizing' are not identical activities. The ability though to think about thinking in the first person is nevertheless related to the ability to think about other's thoughts in the third person. Unclear is how these phenomena influence one another. In this review, we explore how self-reflection and autobiographical memory influence the capacity to think about the thoughts and emotions of others. We review studies suggesting that the more individuals are able to reflect on and retrieve episodes from their life narratives, the more they are likely to grasp others' thoughts and emotions. We discuss evidence supporting this possibility including studies of the neurocognitive bases of empathy and self-awareness and how different aspects of self-reflection may impact on mindreading. We also draw from clinical reports how improved self-reflection may result in a more nuanced mindreading, namely persons suffering from schizophrenia and narcissistic personality disorder. We finally discuss the implications for research and practice and consider whether there are conditions in which the reverse is true, where self-reflection might impair mindreading or in which mindreading may facilitate self-reflection.

A scientific agenda for the concept of recovery as it applies to schizophrenia

Recovery is now a widely discussed concept in the field of research, treatment, and public policy regarding schizophrenia. As it has increasingly become a focus in mainstream psychiatry, however, it has also become clear both that the concept is often used in multiple ways, and that it lacks a strong scientific basis. In this review, we argue that such a scientific basis is necessary for the concept of recovery to have a significant long-term impact on the way that schizophrenia is understood and treated. The discussion focuses on key issues necessary to establish this scientific agenda, including: 1) differences in definitions of recovery and their implications for studying recovery processes and outcomes; 2) key research questions; 3) the implications of data from outcome studies for understanding what is possible for people diagnosed with schizophrenia; 4) factors that facilitate recovery processes and outcomes, and methods for studying these issues; and 5) recovery-oriented treatment, including issues raised by peer support. Additional conceptual issues that have not received sufficient attention in the literature are then noted, including the role of evidence-based practices in recovery-oriented care, recovery-oriented care for elderly people with schizophrenia, trauma treatment and trauma-informed care, and the role of hospitals in recovery-oriented treatment. Consideration of these issues may help to organize approaches to the study of recovery, and in doing so, improve the impact of recovery-based initiatives.

Associations of metacognition and internalized stigma with quantitative assessments of self-experience in narratives of schizophrenia

Observations that diminishment of self-experience is commonly observed in schizophrenia have led to the suggestion that the deepening of self-experience may be an important domain of recovery. In this study we examined whether internalized stigma and deficits in metacognition are possible barriers to the development of richer self-experience. Narratives of self and illness were obtained using a semi-structured interview from 51 persons with schizophrenia spectrum disorder before entry into a rehabilitation research program. The quality of self-experience within those narratives was rated using the Scale to Assess Narrative Development (STAND). These scores were then correlated with concurrent assessments of stigma using the Internalized Stigma of Mental Illness Scale (ISMIS) and metacognition using the Metacognition Assessment Scale (MAS). A stepwise multiple regression controlling for age, social desirability and awareness of illness revealed that higher STAND ratings were significantly associated with greater ratings of metacognitive capacity and lesser ratings of stereotype endorsement. Results suggest that qualities of self-experience expressed within personal narratives of schizophrenia may be affected by internalized stigma and deficits in the capacity to think about one's own thinking and the thinking of others.

Metacognition within narratives of schizophrenia: associations with multiple domains of neurocognition

Research has suggested many with schizophrenia experience impairments in metacognition, or difficulties apprehending their own thoughts and the thoughts of others, and that those deficits are not reducible to a single symptom or cognitive impairment. While links between metacognition and more severe levels of symptoms have emerged, less clear is whether there are consistent associations between metacognition and other neurocognitive capacities. Accordingly the current study sought to examine whether different patterns of metacognition deficits have different neurocognitive correlates. Narratives were gathered from 69 adults with schizophrenia spectrum disorder using the Indiana Psychiatric Illness Interview along with a symptom interview and neurocognitive battery including subtests of the Wechsler Adult Intelligence Scale III, Wechsler Memory Scale III and the Wisconsin Card Sorting Test. Metacognitive capacity within the narrative interview was assessed using the Metacognition Assessment Scale and participants were divided based on those scores into three groups: minimal self-reflectivity/not decentered (n=25); basic self-reflectivity/not decentered (n=33); and basic self-reflectivity/decentered (n=11). Basic self-reflectivity refers to the ability to distinguish one's own thoughts and feelings while decentered refers to the ability to see others as having independent perspectives and relationships with one another. MANOVA and ANOVA comparing groups revealed that the participants lacking basic self-reflectivity had significantly poorer working memory and more symptoms of disorganization, while participants able to see others as having independent perspectives and relationships demonstrated better visual memory. Results suggest different deficits in metacognition may be linked to different neurocognitive capacities.

Toward understanding the insight paradox: internalized stigma moderates the association between insight and social functioning, hope, and self-esteem among people with schizophrenia spectrum disorders

Research has paradoxically linked awareness of illness to both better function outcomes and lesser hope and self-esteem. One possible explanation for these findings is that acceptance of having schizophrenia may impact outcomes differently depending on the meanings the person attaches to this acceptance, particularly whether he or she accepts stigmatizing beliefs about mental illness. To explore this possibility we performed a cluster analysis of 75 persons with schizophrenia spectrum disorders based on single measures of insight using the Positive and Negative Syndrome Scale, internalized stigma using the Internalized Stigma of Mental Illness Scale, and compared groups on concurrent assessments of hope and self-esteem. Three groups were produced by the cluster analyses: low in sight/mild stigma (n = 23), high insight/minimal stigma (n = 25), and high insight/moderate stigma (n = 27). As predicted, analysis of variance-comparing groups revealed that the high insight/moderate stigma group had significantly the lowest levels of hope on the Beck Hopelessness Scale and self-esteem using the Multidimensional Self-esteem Inventory. As predicted, the high insight/minimal stigma group also had significantly less impaired social function than the other groups. Implications for assisting persons to come to cope with awareness of illness and stigma are discussed.

Determinants of functioning and well-being among individuals with schizophrenia: an integrated model

Outcomes for health conditions are typically the result of multiple factors; however, studies tend to focus on a narrow class of variables. Functioning and well-being outcomes for schizophrenia are diverse and have resisted simple explanation; however, prior research has not offered an integrated understanding of the relative contributions of enduring and episodic environmental factors, personal resources and psychiatric factors, and cognitive appraisal and coping, on functioning and well-being outcomes in schizophrenia. The present article sets out an integrated model of the determinants of functioning and well-being among individuals with schizophrenia. To examine evidence that bears on the model, literature on hypothesized relationships is reviewed to identify areas for which there is strong evidence and areas where more research is needed. The article suggests areas for further research, and directs researchers and practitioners toward areas of intervention that can enhance functioning and well-being for persons diagnosed with schizophrenia.

Coping with psychosis: an integrative developmental framework

One important way in which persons with severe mental illness, such as schizophrenia, can influence the recovery process is by coping with the profoundly negative effects of mental illness. Despite accumulating evidence on the active role of the person in his or her recovery, there remains much conceptual confusion regarding the nature and categorization of the concept of coping. The present article constructs a clinically useful framework of coping that describes parallel and consecutive types of coping processes by applying Schwarzer's proactive coping theory to severe mental illness. Four coping modes including reactive, anticipatory, preventive, and proactive are described, and the role of meaning making is elaborated on as an integrative framework. Future research can be directed at validating the presented model and investigating the relationship between these types of coping and other relevant dimensions such as symptoms, functioning, and recovery.

A contextual study of daily living strategies in neurocognitively impaired adults with schizophrenia

Schizophrenia is a severe mental illness often recognized as a degenerative neurocognitive condition. For some with the disorder, the impairment is fairly mild, but for others, neurocognitive abilities can be severely compromised. In this study, 5 individuals with schizophrenia had been assessed through a laboratory-based neurocognitive battery as having severe impairment. Their neurocognitive status was unknown to the author, and she was able to observe daily tasks and ask questions about strategies they employed while completing tasks, and analyze the data without preconceptions about their status. This study was guided by notions of ecological validity, which is the comparison between lab tests and real-world functioning. Despite their cognitive deficits, these individuals had remarkable strengths, which included drawing supportive people into their worlds to fulfill their daily tasks. These data contribute to the rehabilitation literature and propose remedies for struggles of daily living when one has schizophrenia.

Associations of symptoms, psychosocial function and hope with qualities of self-experience in schizophrenia: comparisons of objective and subjective indicators of health

While changes in self-experience have been suggested to be an important element of recovery from severe mental illness, little is known about how qualities of self-experience are linked with other indicators of health including objective measures such as symptoms profiles and subjective measures such as hope. To examine these issues the narratives of self and illness of 65 persons with schizophrenia spectrum disorder were obtained prior to entry into rehabilitation and rated using the Scale to Assess Narrative Development (STAND). STAND scores were then compared with concurrent assessments of hope assessed with the Beck Hopelessness Scale (BHS), psychosocial function using the Quality of Life Scale (QOLS) and symptom profile defined categorically using the Positive and Negative Syndrome Scale (PANSS). Results suggest that higher ratings of the STAND were associated with greater expectations of perseverance on the BHS and higher levels of psychosocial function on the QOL. Lower symptom profiles were similarly linked with higher STAND scores. Results suggest qualities of self-experience expressed within personal narratives are linked to symptom profiles and subjective assessments of health. Theoretical and clinical implications are discussed.

Career development in schizophrenia: a heuristic framework

Adults with schizophrenia continue to have poor rates of competitive employment. We have learned how to support individuals in the workplace with supported employment (SE); but have paid limited attention to early vocational identity development, work antecedents, illness characteristics, and career preferences. Vocational identity development is an important and natural condition of human growth for all persons and is well-researched in career counseling. For young adults with schizophrenia, the predictor of positive work outcome with the most evidence has been that working competitively prior to illness leads to better chances for work post-diagnosis. A heuristic framework is proposed to conceptualize how pre-illness vocational development (paid and unpaid) plus life cycle supports can provide direction to the individual in their work recovery.

The Emerging Self in Conceptualizing and Treating Mental Illness

1. The course of severe mental illnesses is more heterogeneous than previously thought and is influenced by many complex, interacting factors. 2. The experience of self and capacity to cope of people with mental illnesses contribute to the recovery process. 3. Changes in traditional treatment models and a focus on broader societal interventions are needed to facilitate recovery. 4. Psychiatric nurses play an important role in these new developments as evident, for example, in the 3R Program (relapse, recovery, and rehabilitation).